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Inflammation: What Is It, and how can my diet and behavior affect it?

Suppose you’ve been told to eat an anti-inflammatory diet, or maybe you’re a practitioner whose clients want to know whether this is right for them. Before hopping on this buzzy bandwagon, ask yourself ‘For what purpose?’

Without missing a beat, you say ‘Well, to reduce my inflammation!’

While technically a noble intention, let’s first acknowledge that this term is used loosely in everyday conversation, but it’s more misunderstood than one might initially believe. Let’s talk about this elephant in the room, dive in, and answer a few key questions: What’s inflammation in the first place? What factors (dietary and otherwise) contribute to, or mitigate it? And finally, how might we modify our diets and our behavior to reduce it?

 

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What is inflammation?

In broad terms, inflammation is the body’s immune system’s response to a stimulus.1This can be in response to common injuries such as burning your finger, or falling off of a bicycle, after which you feel the affected area become red, warm, and puffy- this is a localized response to injury, characterized by ‘increased blood flow, capillary dilation, leucocyte infiltration, and production of chemical mediators.’2In short, an inflammatory response means the innate (non-specific) immune system is ‘fighting against something that may turn out to be harmful.’

It turns out that while inflammation is often cast in a negative light, it’s actually essential in small amounts for immune-surveillance and host defense.2 In true ‘Goldilocks’ form, too little and too much inflammation both pose problems; in fact, most chronic diseases are thought to be rooted in low-grade inflammation that persists over time. This inflammation may go unnoticed by the host (you!) until overt pathologies arise, which include, but are not limited to, diabetes, cardiovascular disease, nonalcoholic fatty liver disease, obesity, autoimmune disorders, inflammatory bowel disease, and even clinical depression. This concept is called ‘The inflammation theory of disease,’ in which inflammation is the common underlying factor among the leading causes of death.3

How do we measure inflammation?

Although measuring low-grade chronic inflammation (read: A chronic, low-grade immune response) carries a number of limitations, studies frequently measure cellular biomarkers such as activated monocytes, cytokines, chemokines, various adhesion molecules, adiponectin, non-specific markers such as C-reactive protein, fibrinogen, and serum amyloid alpha. Key inflammatory pathways include sympathetic activity, oxidative stress, nuclear factor kappaB (NF-kB) activation, and proinflammatory cytokine production.4 Now you might wonder, ‘What does this mean for me? What modifiable factors can activate my key inflammatory pathways?’ If we are to address this question appropriately, let us turn our attention to both dietary and behavioral moderators.

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What makes up an anti-inflammatory diet?

Prolonged low-grade inflammation is associated with excessive oxidative stress and altered glucose and lipid metabolism in our fat (adipose) cells, muscle, and liver.4 Therefore, research suggests that certain dietary components can modulate these key inflammatory pathways and clinical pathologies. Dr. Barry Sears explains in a review paper that “anti-inflammatory nutrition is the understanding of how individual nutrients affect the same molecular targets affected by pharmacological drugs.” 5

Compelling research from large-scale, longitudinal observational studies including the Women’s Health Initiative Observational Study6 and Multi-Ethnic Study of Atherosclerosis (MESA) study7suggest that a diet with appropriate calories that is low in refined carbohydrates, high in soluble fiber, high in mono-unsaturated fatty acids, a higher omega-3 to omega-6 ratio, and high in polyphenols, all have anti-inflammatory effects on the body. A Mediterranean diet pattern that incorporates olive oil, fish, modest lean meat consumption, and abundant fruits and vegetables, legumes, and whole grains, shows more anti-inflammatory effects when compared to a typical American dietary pattern. Other observational and interventional studies have also suggested that dietary patterns incorporating green and black tea, walnuts, ground flaxseed, and garlic are also associated with reduced inflammation.

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Can my stress levels influence inflammation, too?

To conclude our discussion with anti-inflammatory dietary strategies would be a half-told story. In fact, “Communication between the systemic immune system and the central nervous system (CNS) is a critical but often overlooked component of the inflammatory response to tissue injury, disease or infection.”3

Behavioral studies have shown that prolonged psychological stress can activate the same pro-inflammatory pathways we’ve been discussing all along. While chronic psychological stress can promote over-expression of pro-inflammatory mediators, it can also promote overeating unhealthful foods in the absence of hunger. 8 Repetitively stress-eating calorie-dense, nutrient-poor foods not only further exacerbates psychological distress and creates a vicious cycle of stress-eating, but over time promotes adiposity, which we’ve described is itself a pro-inflammatory state.

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Integrative strategies and considerations

This ‘cross-talk’ between the brain and body suggests that strictly dietary or strictly behavioral interventions are not enough to reduce inflammation on their own. Instead, we must consider integrative diet and lifestyle preventions/interventions simultaneously. Going forward, we’ll need better biomarkers and more research looking at individual responses to diet (personalized nutrition!), and better understanding of how food components and behavioral factors modulate genetic targets involved in the inflammatory response.

 

References:

  1. What is an inflammation? National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0072482/. Published January 7, 2015. Accessed March 16, 2018.
  2. Hunter P. Stress, Food, and Inflammation: Psychoneuroimmunology and Nutrition at the Cutting Edge. EMBO Reports. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3492709/. Published November 2012. Accessed March 16, 2018.
  3. Hunter, Philip. The Inflammatory Theory of Disease. EMBO Reports, Nature Publishing Group, Nov. 2012, ncbi.nlm.nih.gov/pmc/articles/PMC3492709/.
  4. Galland, Leo. “Diet and Inflammation.” Sage, 7 Dec. 2010, journals.sagepub.com/doi/abs/10.1177/0884533610385703?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub=pubmed.
  5. Sears, Barry, and Camillo Ricordi. “Anti-Inflammatory Nutrition as a Pharmacological Approach to Treat Obesity.” Journal of Obesity, Hindawi Publishing Corporation, 2011, ncbi.nlm.nih.gov/pmc/articles/PMC2952901/.
  6. Thomson, C A, et al. “Association between Dietary Energy Density and Obesity-Associated Cancer: Results from the Women’s Health Initiative.” Journal of the Academy of Nutrition and Dietetics., U.S. National Library of Medicine, ncbi.nlm.nih.gov/pubmed/28826845.
  7. “Associations of Dietary Long-Chain n-3 Polyunsaturated Fatty Acids and Fish With Biomarkers of Inflammation and Endothelial Activation (from the Multi-Ethnic Study of Atherosclerosis [MESA]).” The American Journal of Cardiology, Excerpta Medica, 4 Mar. 2009, www.sciencedirect.com/science/article/pii/S0002914909001088?via=ihub.
  8. Tryon, M., Carter, C., DeCant, R. and Laugero, K. (2013). Chronic stress exposure may affect the brain's response to high calorie food cues and predispose to obesogenic eating habits. Physiology & Behavior, 120, pp.233-242.

A Time for Change: Nutrition Education in Medicine

The New England Journal of Medicine recently published an article entitled “Simulation of Growth Trajectories of Childhood Obesity into Adulthood.” The models in the study projected that 57.3% of today’s children will be obese by age 35.1 The bleak predictions of future health trends such as these reaffirm the need for health professionals to be knowledgeable about nutrition.

Patients expect physicians to be sources of information related to nutrition. In fact, 61% of respondents to an American Dietetic Association (now the Academy of Nutrition and Dietetics) survey stated that they believe physicians are a “very credible” source of nutrition information.2 At the same time, though, in a study of internal medicine interns, 86% of respondents admitted to being inadequately trained to provide nutritional counseling. This inadequacy starts early in a physician’s career, with 51.1% of medical school graduates in 2005 reporting that they received insufficient nutrition education during medical school.3

Take the field of cardiology, for example, where a recent study found that, among a cohort of 930 cardiologists, 90% believe their role includes providing patients with basic nutrition information. In the same group of physicians, though, 90% stated that they had received little-to-no training in nutrition during their fellowship, 59% stated that they had received no nutrition during internal medicine training, and 31% reported no nutrition education in medical school.4 Simply put, the perceived role of physicians and the training they are given don’t match up.

This is not a matter of self-reported opinion either, because curricula also lack dedicated nutrition training, and this is not a new phenomenon. In 1962, the American Medical Association (AMA)’s Council on Foods and Nutrition held a conference pertaining to the “inadequate recognition, support and attention” given to nutrition education in medical schools. The council acknowledged that nutrition is intimately involved in the pathogenesis of chronic and degenerative diseases and that the medical curriculum was lagging with respect to advances in nutrition science. 5 The interrelatedness of medicine and nutrition was recognized by the council as more than the just the treatment of isolated nutrient deficiencies.

In 1976, the AMA conducted a mail survey to better understand the status of nutrition education in U.S. medical schools. When 102 medical schools responded to the surveys, fewer than 20% of schools reported requiring a nutrition course.6 The schools cited lack of funds, inadequate number of physicians trained in clinical nutrition, and limited amount of time available in the curriculum as limitations for increased nutrition education. This forty-year-old survey also highlighted the increased interest in nutrition from students and faculty at these institutions.7 We can only assume this interest has since grown.

The scientific conferences and congressional hearings in the decades leading up to the 80s drew attention to the need to improve nutrition education in U.S. medical schools. As a result, the National Research Council Committee on Nutrition in Medical Education published recommendations in 1985 stating that a minimum of 25 to 30 classroom hours during preclinical years should be allotted to covering the topics in nutrition that were underscored by the committee.6 For the past two decades, research spearheaded by University of North Carolina at Chapel Hill has tracked the state of nutrition education in U.S. medical schools every four years. Unfortunately, the data show no sign of changes in the average hours required in nutrition education since 2000. The most recent survey during the 2012-2013 academic year included 121 medical schools, with an average of 19 hours (SD =13.7) of nutrition education in their curriculum. The survey showed that 71% of medical schools failed to meet the minimum recommendation of 25 hours, 36% provided 12 or fewer hours, and 9% provided none.8

Current nutrition education is evidently not translating into practice when only 10% of primary care physicians include weight counseling for patients, and fewer than half of obese and overweight patients are advised to lose weight.9 Primary care practitioners overwhelmingly support requiring additional training so that they will be better informed about the care they provide to their patients with obesity.10

The Association of American Medical Colleges has recently declined to incorporate nutrition into its new blueprint for medical competencies.11 The 2013 American Council for Graduate Medical Education (ACGME) program requirements for Graduate Medical Education in Cardiovascular Disease neglects to mention nutrition. 12 This continues to be the case in the most recent iteration of the ACGME requirements along with the ACGME for Internal Medicine.13,14 These examples show that both medical schools and graduate medical education have yet to legitimize the value of incorporating nutrition training through their competencies.

Three programs that have become recognized for their innovative approach to nutrition curriculum at medical schools include:

  1. The Nutrition in Medicine (NIM) Project – since 1995 this program has aided in the development and distribution of nutrition curriculum for medical students through comprehensive online courses free of charge. The curriculum is a 29-unit curriculum covering basic science content along with clinical applications through cases. About 50% of medical schools actively use the NIM curriculum and the flexibility of the curriculum has allowed for varied implementation at these schools .15 A more recent initiative by the NIM team is the Nutrition Education for Practicing Physicians for residents, fellows, and practicing physicians. These online modules differ from the medical school resources through the greater level of clinical detail and practical applications (http://www.nutritioninmedicine.org/).
  2. Healthy Kitchens, Healthy Lives – The Culinary Institute of America and the Harvard T.H. Chan School of Public Health have collaborated as a strategy to enhance physician ability and motivation for nutrition counseling through interactive cooking experiences. The program uses teaching kitchens to demonstrates how nutrition science can be translated into nutritious meals. This initiative has shown to be successful in changing physicians’ dietary practices and their inclination to offer nutrition counseling at a 3-month follow-up.16 Currently, over 6,000 health professionals have taken the course. This initiative has expanded to 32 organizations located in 16 different states, plus Italy and Japan. The kitchens are active in universities, hospitals, and corporate buildings. (http://www.healthykitchens.org/)
  3. Tulane University School of Medicine’s Goldring Center for Culinary Medicine – this is the first teaching kitchen implemented at a medical school. The center trains medical students and professionals through culinary medicine classes in the form of electives and seminars as well as continuing education. The idea is grounded in the idea that the knowledge to cook nutritious meals encourages patients to buy vegetables and fruits that they previously avoided because they didn’t know how to prepare them. Tulane offers an institutional and away rotation at Johnson & Whales University in Providence Rhode Island where students can participate in hands-on culinary and culinary nutrition classes as well as an academic research project related to medical nutrition therapy. Medical students can also opt to take an 8-class culinary medicine elective during their first or second year of school. (https://culinarymedicine.org/)

The physician is the head of the care team and is responsible for directing care and allocating personnel and resources. Physicians see many patients when they are most in need of nutrition guidance. Therefore, physicians should be able to assess and recognize nutrition-related problems, and appropriately coordinate patient care. Let us hope that these programs are increasingly adopted in medical education so that physicians will be better equipped to address the health of their patients.

 

References:

  1. Ward ZJ, Long MW, Resch SC, Giles CM, Cradock AL, Gortmaker SL. Simulation of Growth Trajectories of Childhood Obesity into Adulthood. N Engl J Med. 2017;377(22):2145-2153. doi:10.1056/NEJMoa1703860.
  2. Nutrition and You: Trends 2008.; 2008. http://www.eatrightpro.org/~/media/eatrightpro files/media/trends and reviews/nutrition and you/trends_2008_are_you_already_doing_it.ashx. Accessed November 30, 2017.
  3. Vetter ML, Herring SJ, Sood M, Shah NR, Kalet AL. What do resident physicians know about nutrition? An evaluation of attitudes, self-perceived proficiency and knowledge. J Am Coll Nutr. 2008;27(2):287-298. http://www.ncbi.nlm.nih.gov/pubmed/18689561. Accessed November 30, 2017.
  4. Devries S, Agatston A, Aggarwal M, et al. A Deficiency of Nutrition Education and Practice in Cardiology. Am J Med. 2017;130(11):1298-1305. doi:10.1016/j.amjmed.2017.04.043.
  5. Council on Foods and Nutrition. JAMA. 1963;183(11):955. doi:10.1001/jama.1963.03700110087015.
  6. National Research Council (US) Committee on Nutrition in Medical Education. Nutrition Education in U.S. Medical Schools. Washington, DC; 1985. doi:10.1007/BF02427708.
  7. Cyborski CK. Nutrition content in medical curricula. J Nutr Educ. 1977;9(1):17-18. doi:10.1016/S0022-3182(77)80110-6.
  8. Adams KM, Butsch WS, Kohlmeier M. The State of Nutrition Education at US Medical Schools. J Biomed Educ. 2015;2015:1-7. doi:10.1155/2015/357627.
  9. Kraschnewski JL, Sciamanna CN, Pollak KI, Stuckey HL, Sherwood NE. The epidemiology of weight counseling for adults in the United States: a case of positive deviance. Int J Obes. 2013;37(5):751-753. doi:10.1038/ijo.2012.113.
  10. Bleich SN, Bennett WL, Gudzune KA, Cooper LA. National survey of US primary care physicians’ perspectives about causes of obesity and solutions to improve care. BMJ Open. 2012;2(6):e001871. doi:10.1136/bmjopen-2012-001871.
  11. Englander R, Cameron T, Ballard AJ, Dodge J, Bull J, Aschenbrener CA. Toward a Common Taxonomy of Competency Domains for the Health Professions and Competencies for Physicians. Acad Med. 2013;88(8):1088-1094. doi:10.1097/ACM.0b013e31829a3b2b.
  12. Devries S, Dalen JE, Eisenberg DM, et al. A deficiency of nutrition education in medical training. Am J Med. 2014;127(9):804-806. doi:10.1016/j.amjmed.2014.04.003.
  13. ACGME Program Requirements for Graduate Medical Education in Cardiovascular Disease (Internal Medicine). https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/141_cardiovascular_disease_2017-07-01.pdf. Accessed November 30, 2017.
  14. ACGME Program Requirements for Graduate Medical Education in Internal Medicine.; 2017. http://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/140_internal_medicine_2017-07-01.pdf. Accessed November 30, 2017.
  15. Adams KM, Kohlmeier M, Powell M, Zeisel SH. Nutrition in medicine: nutrition education for medical students and residents. Nutr Clin Pract. 2010;25(5):471-480. doi:10.1177/0884533610379606.
  16. Eisenberg DM, Myrdal Miller A, McManus K, Burgess J, Bernstein AM. Enhancing Medical Education to Address Obesity: “See One. Taste One. Cook One. Teach One.” JAMA Intern Med. 2013;173(6):470. doi:10.1001/jamainternmed.2013.2517.

 

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How can we implement better health behaviors in cancer survivors?

Lifestyle interventions targeted at obtaining/maintaining a healthy body weight and/or incorporating physical activity and healthy eating habits have great potential in improving outcomes in cancer survivors. Cancer diagnosis is a “teachable moment” wherein many patients are highly motivated to make changes (1). Furthermore, a balanced diet and moderate exercise can improve prognosis, quality of life, physical function, and survival across the cancer continuum. As such, groups such as the Amercian Cancer Society, National Comprehensive Cancer Network and the American College of Sports Medicine have released lifestyle guidelines for cancer survivors.

However, implementing changes in individuals and healthcare systems is challenging, to say the least. This is a recent topic covered by Karen Basen-Engquist and a number of colleagues as part of a special Issue of Obesity (Transdisciplinary Research on Energetics and Cancer)(2). Their article provides a 6-point agenda for translating research into clinical and community action, as follows:

  1. Increase the availability of different types of activities for weight management, nutrition counseling, and physical activity. One size will never fit all when it comes to improving health. Individual goals/preference, resources, and logistics all come into play, and cancer-specific programs may be needed.
  2. Improve screening and referral to lifestyle interventions. A system for evaluating and triaging patients for health programs should be developed. Importantly, an individual’s physical status, health needs, and goals should be considered.
  3. Improve the health care provider’s ability to screen, assess, and refer survivors for lifestyle programs. Oncology providers have a powerful role in helping cancer survivors; however, they often do not feel confident in screening, giving advice, or administering recommendations for lifestyle-related constructs. Implementation of processes such as the 5As (Ask, Advise, Assess, Assist, Arrange), which has been successful in tobacco cessation (3) and obesity management (4) might prove beneficial.
  4. Expand the support of oncology-specific professional training and certification. Professional organizations of dietitians, exercise professionals, psychiatrists, and physical therapists have additional certification programs for oncology or are working on developing one for its members. However, professionals with specific expertise in oncology are still greatly needed to address the unique needs of this population.
  5. Expand dissemination and implementation research. Many research programs do not address how a program could be implemented in a real-world setting (external validity). Dissemination of research findings with consideration of the sustainability and generalizability of programs is essential for broader impact.
  6. Advocate for health care policies that support lifestyle services for cancer survivors. Coverage for health programs is highly variable and often has barriers such as large co-payments, no coverage in grandfathered plans, and cost sharing. A potential solution could be incentivizing nutrition and exercise services, although more research is needed to determine the effectiveness of such actions.

As the authors eloquently articulate, the time has come to enable research into action for optimal healthcare in all cancer survivors.

References:

  1. Demark-Wahnefried W, Aziz NM, Rowland JH, Pinto BM. Riding the crest of the teachable moment: promoting long-term health after the diagnosis of cancer. J Clin Oncol 2005;23:5814–30.
  2. Basen-Engquist K, Alfano CM, Maitin-Shepard M, Thomas CA, Schmitz KH, Pinto BM, et al. Agenda for Translating Physical Activity, Nutrition,and Weight Management Interventions for Cancer Survivors into Clinical and Community Practice. Obesity 2017; 25, S9-S22.
  3. Siu AL, Force USPST. Behavioral and pharmacotherapy interventions for tobacco smoking cessation in adults, including pregnant women: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2015;163:622-634.
  4. Rueda-Clausen CF, Benterud E, Bond T, Olszowka R, Vallis MT, Sharma AM. Effect of implementing the 5As of Obesity Management framework on provider-patient interactions in primary care. Clin Obes 2013; 4, 39-44.

 

Dietary Guidelines Committee Focuses on the Diet-Health-Environment Trilemma

By Banaz Al-khalidi

First released in 1980, the Dietary Guidelines for Americans are updated and jointly published by the U.S. Department of Agriculture (USDA) and the U.S. Department of Health and Human Services (HHS) every 5 years. These guidelines provide recommendations on nutrition and physical activity for Americans aged 2 and older, and are the driving force behind Federal nutrition policies, nutrition education and food procurement programs. As such, these guidelines are used by both the public and industry, and by a wide variety of audiences including educators, health professionals and government agencies.

Earlier the 2015 Dietary Guidelines Advisory Committee (DGAC) released a Scientific Report based on the latest evidence, which will shape the finalized guidelines later this year. The committee’s work was influenced by two fundamental connections between nutrition and lifestyle-related health issues facing the U.S population:

1) Chronic diseases, overweight and obesity: about half of all American adults (~117 million) have one or more preventable chronic diseases such as type 2 diabetes, cardiovascular diseases, hypertension, and diet related cancers, and about two-thirds of adults and one-third of children are overweight or obese due to poor dietary habits and physical inactivity.
2) Food environment and settings: diet and lifestyle behaviors are strongly influenced by personal, social, organizational, and environmental context and systems. As such, the DGAC developed their recommendations based on a conceptual model of socio-ecological framework to provide recommendations at the individual, social, organizational, and environmental level.

What does the DGAC’s report say about the latest research on diet and lifestyle-related health outcomes?

The DGAC found that the current average American diet is low in vegetables, fruits, and whole grains and too high in refined grains, added sugars, saturated fat, and sodium. Furthermore, inadequate consumption of vitamin D, calcium, fiber, and potassium were categorized as nutrients of public health concern for the majority of the U.S population. Lifestyle-related health problems in the U.S. have persisted for more than 2 decades and the DGAC’s report calls for urgent preventative actions at the national, state, and local community levels. The DGAC recommended a shift in focus to a more environmentally friendly, sustainable plant-based diet that focuses on whole foods rather than specific nutrients. The overall body of evidence examined by the committee is summarized below:

“A diet higher in plant-based foods, such as vegetables, fruits, whole grains, legumes, nuts, and seeds, and lower in calories and animal based foods is more health promoting and is associated with less environmental impact than is the current U.S. diet.”

This is not to say that any food groups need to be eliminated completely to improve health and sustainability outcomes. In fact, the DGAC recommended three dietary patterns to provide options that can be adopted by the U.S. population and are also aligned with lower environmental impacts. These dietary patterns include the Healthy U.S. style Pattern, the Healthy Mediterranean style Pattern, and the Healthy Vegetarian Pattern. Furthermore, the 2015 DGAC left out cholesterol restrictions where previously, the 2010 DGAs recommended that cholesterol intake be limited to no more than 300 mg/day. The up-to-date evidence on cholesterol showed no substantial relationship between dietary consumption of cholesterol and blood cholesterol. Thus, the 2015 DGAC concluded, “Cholesterol is not a nutrient of concern for overconsumption.”

The message is clear—the 2015 DGAC recommends the U.S population consume dietary patterns that are rich in vegetables, fruits, whole grains, seafood, legumes, and nuts; moderate in low- and non-fat dairy products and alcohol; lower in red and processed meat; and low in saturated fat (less than 10% of total calories consumed per day), added sugars (maximum of 10% of total calories consumed per day), and sodium (2,300 mg per day or age-appropriate Dietary Reference Intake amount). Whether the USDA and the HHS will choose to adopt or ignore these recommendations put forth by the 2015 DGAC remains uncertain at this point. Meanwhile, dozens of health and environmental groups support the committee’s recommendations regarding sustainability, as viewed in the open letter found at My Plate My Planet, Food for a Sustainable Nation.

The advisory recommendations put forth by the 2015 DGAC are also closely aligned with recent research highlighting the urgency of shifting global diets, where healthy dietary patterns (i.e. Vegetarian, Pescetarian, and Mediterranean diets) are found to be associated with more favorable health as well as environmental outcomes. Thus, the available data strongly suggest that diets that are higher in plant-based foods will not only improve personal and public health, but also boost our planet’s health via “weight” reduction in greenhouse gases mainly due to reduction in livestock production.